Laparoscopic Vs. Open Ventral Hernia Repair
Irina Kovatch, MD Brooklyn VA Hospital Morbidity and Mortality January 12th, 2012
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Case Presentation
63 yo M with symptomatic recurrent ventral hernia
PMH: HTN, hypercholesterolemia
PSH: primary repair of ventral hernia in 2009, repair of bilateral inguinal hernias in 1980s
Meds: lipitor, lotril
NKDA
SH: former smoker (quit 25 years ago)
PE: moderate size incisional hernia, reducible
BMI: 33.6 after 81lb of intentional weight loss
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OR – August 31, 2011
Laparoscopic approach - open Hasson technique
Findings: ~10x15cm defect with omentum adherent to the sac
Repair with Physiomesh (20x25cm) and SecureStrap tacks
Uneventful recovery and discharge home on POD 5
Outpatient follow-up as of Nov 8, 2011 – no recurrence
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Abdominal Wall Hernias
Common problem encountered by surgeons
Despite the large volume of hernia repairs performed, there remains no single best technique
Many issues continue to influence the evolution of ventral hernia repair methods
increasing laparoscopic experience
influx of new mesh materials into the market
changing patient population
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Ventral Hernias
Incisional - develop in up to 13% of patients who undergo a midline laparotomy (>28% if a wound infection develops)
Epigastric - frequent in obese individuals with attenuated tissues
Umbilical - congenital in origin, but may occur later in life resulting from aging and increases in abdominal girth and pressure
Repair of all of these defects frequently requires the use of a prosthetic material to achieve a lasting repair
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Indications for Repair
Pain and discomfort that limit patient’s ability to perform activities of daily life
Risk for incarceration and strangulation of visceral organs
Abdominal wall dysfunction that decreases quality of life
Bulge in the abdominal wall that negatively affects appearance
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Hernia Repair
Sutured closure alone is often inadequate to provide a durable repair
Defect <4 cm could be considered for primary closure unless predisposing factors for recurrence are present
obesity, smoking, steroid usage, advanced age
Defects >4 cm should always be repaired with a prosthesis unless an associated infection or other source of contamination is present
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Mesh
Mesh products can be used either laparoscopically or in the open technique
The open tissue repair has recurrence rates of 25-50% without mesh, and 10-25% for inlay repair with mesh
Because of the high recurrence rate, the use of any mesh as a bridge is contraindicated in most instances (with exception of infection or open abdomen)
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Underlay Method
Biomaterial is applied to the undersurface of the abdominal wall with strong fixation
Provides the most durable repair
Minimum overlap of the fascial defect by the prosthesis should be 3 cm (4-5 cm in high-risk patients)
Application of the mesh in the open technique can be difficult, and transfascial sutures are required to adequately fixate the biomaterial
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Large Hernias
Hernias larger than 15-18 cm, especially in lateral dimension, are increasingly being seen
Component separation technique is increasingly being used in these cases
For extreme cases, the application of progressive pneumoperitoneum to increase the intraabdominal cavity may aid in the final closure
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Laparoscopic Approach
Laparoscopic repair of ventral hernias is one of the fastest growing minimally invasive techniques
Mesh is placed inside the peritoneal cavity with wide overlap of the hernia defect
Intraabdominal pressure acts to fix the mesh in place, and forces are dispersed over the entire abdominal wall
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Benefits of Laparoscopic Approach
Laparoscopic approach allows for clear visualization of the abdominal wall, wide mesh coverage beyond the defect, and secure fixation to abdominal wall fascia
Associated with a reduction in postoperative pain, decreased morbidity (esp. wound infections), shorter length of stay, decreased costs, and a quicker recovery time
Recurrence rates with laparoscopic approach average at ~5%
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Laparoscopic Approach – Limitations
Leaves some patients with an abdominal wall bulge and persistent abdominal wall dysfunction
Hernia defect is not closed, and the hernia sac is left in place
Postop seroma rate after elective laparoscopic ventral hernia repair
56% on clinical examination, 100% on US
In 16% seromas persist for 6 weeks or longer, cause chronic pain, or become infected
Some require therapeutic intervention
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Laparoscopic Approach – Technique
Access: open Hasson technique, Veress needle, and direct laparoscopic guidance
Lysis of adhesions to the abdominal wall using blunt and sharp dissection
Bleeding is controlled with pressure, hemoclips, or electrocautery
Enterotomies may be repaired laparoscopically or through an open incision (delay mesh placement after 3-5 days on Abx)
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Laparoscopic Approach – Technique
After the hernia is completely reduced the defect is measured using spinal needle/umbilical tape/ruler
Mesh should overlap all fascial defect margins by at least 5 cm
Using a transfascial suture passer cardinal sutures are placed to anchor the mesh
Tacks applied at 1cm interval at the outer edge of the mesh
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Absorbable Tacks
Absorbable tacking devices fix the product and disappear after 3 to 12 months
The use of these products is appealing, but there are no long-term data on them
If these are chosen, it is best to place transfascial sutures to ensure a secure repair until such a time as data prove them unnecessary
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Laparoscopic Approach – Defect Closure
Primary closure may be performed prior to placement of the mesh in select patients (seldom feasible, but might result in decreased seroma formation)
Placement of a mesh with dimensions similar to what would be placed in the absence of fascial closure is recommended
If primary approximation is difficult, a bilateral laparoscopic myofascial separation of components and advancement may be performed
Closure of defect does not reduce recurrence rates and could result in more pain for the patient, so most surgeons do not employ it
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Laparoscopic Approach – Defect Closure
Primary closure may be performed prior to placement of the mesh in select patients
Placement of a mesh with dimensions similar to what would be placed in the absence of fascial closure is recommended
If primary approximation is difficult, a bilateral laparoscopic myofascial separation of components and advancement may be performed
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Perioperative Considerations: Enterotomy
Extensive lysis of adhesions is often required
Small bowel injuries can be catastrophic, especially if they are missed
Nearly 20% of open adhesiolysis operations may result in inadvertent enterotomy
Enterotomy has been reported in an average of 1% of patients in all large series of laparoscopic ventral hernia repair
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Perioperative Considerations: Enterotomy
Management varies according to the type and extent of the injured intestine and the type of mesh available
Small lacerations in the small intestine or bladder without contamination are not an absolute contraindication to mesh placement
Placement of standard mesh in the presence of significant contamination is contraindicated
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Perioperative Considerations: Enterotomy
If fecal spillage is present and a prosthetic is required
bowel should be repaired
adhesiolysis completed
patient placed on antibiotics
delayed hernia repair is performed in 3-4 days if there are no signs of infection
biologic or natural tissue may be used, although the long-term durability of these repairs is worse
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Perioperative Considerations: Pain
PCA is useful until the patient is transitioned to PO
Postop pain after open retrorectus or laparoscopic repair is noted at sites of full-thickness transfascial sutures
Suture site discomfort may last 2-4 weeks postop and is effectively treated by subfascial injections
Long-term complaints after laparoscopic repair are 2-4%
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Perioperative Considerations: Seroma
Ubiquitous in the early postop period regardless of the approach but rarely require any intervention
Drains are recommended with open repairs
Expectant management is the preferred approach to all asymptomatic seromas
Aspiration of fluid is performed if significant or persistent symptoms are present or if there is a question regarding infection
Long-term problems are rare
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Perioperative Considerations: Wound Complications
12-18% develop wound complications after open prosthetic repair
large abdominal incisions
wide tissue dissection with the creation of flaps
placement of a prosthetic
Laparoscopic approach has dramatically reduced wound-related morbidity
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Perioperative Considerations: Wound Complications
The consequences of any mesh infection are severe regardless of how the prosthetic was originally placed
Traditional recommendation is to remove contaminated or exposed prosthetics
associated morbidity is high
mesh removal often results in recurrence, an open wound, and a larger hernia
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Perioperative Considerations: Wound Complications
Mesh removal is not mandatory
Infected polypropylene, polyester, and ePTFE mesh is often capable of being salvaged
intravenous antibiotics
local wound debridement
VAC
subsequent soft tissue coverage of the granulated mesh
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Br J Surg. 2009 Aug;96(8):851-8. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Forbes SS, Eskicioglu C, McLeod RS, et al. Methods: Randomized controlled trials comparing laparoscopic and
open incisional or ventral hernia repair with mesh that included data on effectiveness and safety were included in a meta-analysis.
Results: Eight studies met the inclusion criteria. There was no difference between groups in hernia recurrence rates (relative risk 1.02). Duration of surgery varied. Mean length of hospital stay was shorter after laparoscopic repair in six of the included studies; the longest mean stay was 5.7 days for laparoscopic and 10 days for open surgery. Laparoscopic hernia repair was associated with fewer wound infections (relative risk 0.22), and a trend toward fewer hemorrhagic complications and infections requiring mesh removal.
Conclusion: Laparoscopic repair of ventral and incisional hernia is at least as effective, if not superior to, the open approach in a number of outcomes.
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Surg Endosc. 2009 Jan;23(1):4-15. Epub 2008 Oct 15. Laparoscopic ventral hernia repair: a systematic review Pham CT, Perera CL, Watkins DS, et al.
Method: A systematic review with comprehensive searches identifying six randomized controlled trials (RCTs) and eight nonrandomized comparative studies
Results: The laparoscopic approach has a lower recurrence rate than the open approach and required a shorter hospital stay. Open approach complications generally were wound related, whereas the laparoscopic approach reported both wound- and procedure-related complications and these appeared to be less frequently reported.
Conclusion: The laparoscopic approach may be more suitable for straightforward hernias, with open repair reserved for the more complex hernias. Laparoscopic ventral hernia repair appears to be an acceptable alternative that can be offered by surgeons proficient in advanced laparoscopic techniques.
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Open vs. Laparoscopic
There have been six prospective randomized trials comparing laparoscopic versus open techniques for ventral hernia repair
They consist of small study populations with short-term follow-up and use laparoscopic and open techniques that significantly vary between studies, making results difficult to interpret
Laparoscopic repair of ventral hernias is a safe, feasible, and effective alternative to open ventral hernia repair, and it has the benefits of shorter operative times and hospital stays and lower incidence of postoperative complications
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Referrences
Laparoscopic Ventral and Incisional Hernia Repair. Scott R. Philipp, MD, Bruce J. Ramshaw, MD. Cameron: Current Surgical Therapy, 10th ed. Copyright © 2010 Churchill Livingstone, An Imprint of Elsevier.
Chapter 47 - Ventral Herniation in Adults. Yeo: Shackelford's Surgery of the Alimentary Tract, 6th ed. Copyright © 2007 Saunders, An Imprint of Elsevier.
Br J Surg. 2009 Aug;96(8):851-8. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Forbes SS, Eskicioglu C, McLeod RS, et al.
Surg Endosc. 2009 Jan;23(1):4-15. Epub 2008 Oct 15. Laparoscopic ventral hernia repair: a systematic review Pham CT, Perera CL, Watkins DS, et al.
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